Manage Compliance to be CMS Audit-ready


If your health plan struggles to stay current with the evolving Centers for Medicare & Medicaid Services (CMS) regulatory rules, you are not alone. However, recognizing the importance of compliance and developing a compliance culture within your organization are essential to minimizing risk and reducing shortfalls in meeting CMS standards, particularly when faced with a CMS audit.

In the absence of effective compliance management, valuable time is spent reacting to regulatory compliance, auditing, and monitoring requirements. The result is operational disruption and major pressure on compliance organizations, including the threat of large out-of-pocket expenses. In any given year, health plans that serve the Medicare markets are cited millions of dollars in civil monetary penalties for non-compliance.

Taking the time to develop a robust compliance program for your health plan is a necessity if you wish to operate ethically and with integrity. 

Be CMS Audit-ready at All Times

With engagement letters coming out in March, continuing through July, it is imperative to be prepared for a CMS program audit. We developed Online Monitoring Tool solution (OMT) to automate health plans’ compliance efforts and bring flexibility—and a high level of transparency—to performance monitoring and ongoing auditing. The 2021 audits will include the following program areas for which you must be prepared:

      • CDAG: Part D Coverage Determinations, Appeals, and Grievances
      • CPE: Compliance Program Effectiveness

      • FA: Part D Formulary and Benefit Administration

      • MMP- SARAG: Medicare-Medicaid Plan Service Authorization Requests, Appeals, and Grievances

      • MMP- CCQIPE: Medicare-Medicaid Plan Care Coordination Quality Improvement Program Effectiveness

      • ODAG: Part C Organization Determinations, Appeals, and Grievances

      • SNP-MOC: Special Needs Plans–Model of Care

Audits is one of seven modules in the OMT toolkit. Designed for CMS audit preparedness and regular internal auditing, the Audits module offers complete flexibility. You can audit one requirement, an entire part of a process, or mirror CMS.

The most valued feature of the Audits module is the structured mock program audit experience. Utilizing the latest CMS audit protocols, Audits provides your health plan with a look at how it might perform in a CMS program audit. At the same time, the mock audit approach allows you to correct any noted deficiencies before CMS arrives. 

A mock program audit helps plans prepare for an actual CMS audit by:

      • Identifying resources
      • Uncovering gaps in processes

      • Enhancing communication with first tier, downstream and related entities (FDRs)

        • Including evaluating their ability to assist in audit activities, such as compiling universes

      • Populating member universes, which would be due 15 days after receiving an audit engagement letter

      • Validating member universes

Expert Vendor is a CMS Audit “Partner”

The OMT toolkit supports the functions and processes that most health plans’ compliance departments struggle with the most, and is maintained by a team driven to ensure compliance with CMS regulations and health plan operations.

Your vendors should be there to provide support before, during and after an audit, preparing your health plan for the short and long-term.

At Convey, we begin by helping a health plan evaluate its strengths, weaknesses, and level of overall compliance to prevent exposures that may place it at risk. With this information, the health plan can make informed decisions for necessary business improvements that will reduce the risk of CMS compliance actions, material financial loss, or damage to the organization’s reputation.

Don’t wait for a CMS audit to inform you where your deficiencies are. With OMT, you can monitor adherence to CMS program requirements and ensure your health plan is consistently compliant with regulatory rules.

To request a demo of Convey’s Online Monitoring Tool and learn more about our  CMS audit support,contact us today.